1. Are you a United States citizen? Check “Yes” or “No” . . If you checked “Yes,’’ skip line 2 and go to line 3. If you checked “No,’’ go to line 2. 2. Benefit Eligibility for Noncitizens . . . . . . . . . . . . . . . . . . . . If you are not a citizen of the United States, go to page 15. If you have a qualifying alien status for the United States, enter your alien status code from the chart on page 15 on line 2a. Then enter your alien registration number on line 2b and your date of entry into the United States on line 2c. 3. Check the appropriate box if you were one of the following on December 31, 2002: A. 62 years or older (see Note on page 7, line 3a) . . . . B. Under 62 and blind . . . . . . . . . . . . . . . . . . . . . . . . . . C. Under 62 and disabled (not blind) . . . . . . . . . . . . . . 4. Enter your date of birth (example: 0 5/ 2 1 / 1 9 3 8) . . . . . You must enter your date of birth MM DD Y Y Y Y

• • • • • • • •

1. 2a. 2b. 2c.

YES

NO

Alien Status Code Alien Registration Number Date of Entry

A B C 4.
Date of Birth

See instructions on page 7 and page 8 to see if you must attach a proof document to your claim. If you cannot check one of the boxes, STOP HERE. You do not qualify to file for a Renter Assistance claim.

STEP C

Rental • 5. ________months Information 6. If the address where you lived during 2002 is different than the address you
Complete line 5 through line 7.

entered in Step A, or if the address in Step A is a post office box, enter your 2002 residence address. (If more than one rented residence attach a list.)
Street Address City

¼_________________________________________________________________________________________
State and ZIP Code

¼___________________________________________ RENTED FROM ________________ TO ________________ 7. Enter the name, address, and telephone number of your landlord or the person to whom you paid rent during 2002.
NAME ___________________________________________________________________________________________________________ ADDRESS ______________________________________________________________________________ APT. OR UNIT NO._________ CITY _______________________________________________________ STATE and ZIP CODE______________________________ TELEPHONE ____________________________________________________

Reminder
If this is your first year filing a Renter Assistance claim and you did not receive SSI, please provide proof of your age, disability, or blindness. If you filed a claim last year and are under 62 years old, you will need to provide proof of your temporary disability if you did not receive SSI. (This is an annual requirement.)

STEP H
Signature, date, and telephone number

Caution: To avoid delay of your check, be sure to provide all requested information, sign below, and mail to: FRANCHISE TAX BOARD, PO BOX 942886, SACRAMENTO CA 94286-0904.
I authorize the Franchise Tax Board to match my name and the information provided herein, as well as information necessary to process my claim, against information gathered from public records, the files of the Department of Health Services, and other state or federal agencies to confirm my eligibility for the Renter Assistance Program. Under penalties of perjury, I declare that this claim and all statements regarding my eligibility and citizenship or alien status, including accompanying schedules and any additional information I may provide to the Franchise Tax Board are to the best of my knowledge, true, correct, and complete.

Worksheet to Figure the Amount of Renter Assistance, form FTB 9000R
You may, however, figure this amount as follows: If you were a qualified renter for all of 2002, your allowable assistance will be based on the total household income (form FTB 9000R, line 16) as shown in the Renter Assistance Schedule below. If you were a qualified renter for less than 12 months during 2002 complete line 1 through line 4 to figure your assistance. 1. Enter the amount of assistance from the Renter Assistance Schedule below for your total household income shown on form FTB 9000R, line 16 . . . . . . . 1. 2. Enter the total number of months during 2002 that you lived in a qualified rented residence in California shown on form FTB 9000R, line 5 . . . . . . . . . . . . . . . 2. 3. Multiply the amount on line 1 by the number on line 2 . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Divide the answer on line 3 by 12 (months). This is your allowable assistance. Enter this amount on form FTB 9000R, line 17 . . . . . . . . . . . . . . . . . . . 4. $ 347.50 __________ x __________ $ 0.00 __________ $ $0.00 __________